Form Approved 

OMB No. 

0920-0338 

Exp.01/31/2026

Recommended Format for Smokeless Tobacco Nicotine Data Reporting - CSTHEA 

Please attach additional pages if necessary 

Date 

Office on Smoking and Health 

Attn. FCLAA Program Manager 

4770 Buford Hwy., NE, MS S107-7 

Atlanta, GA 30341 

This nicotine report is being submitted pursuant to the Comprehensive Smokeless Tobacco Health Education Act (CSTHEA), 15 U.S.C. 

§4403(a). 

Manufacturer* (Please indicate if the product is manufactured for another company) 

Variety (Including brand families and brand variations) 

Brand Name (e.g., Skoal Bandits, Skoal Long Cut Cherry, Skoal Long Cut Wintergreen, etc.) 

*If this Ingredient Report is submitted by a designated individual or entity on behalf of a smokeless tobacco manufacturer, packager, or importer, the form must 

specify on whose behalf the submission is being made. 

Public reporting burden of this collection of information is estimated to average 1,706.5 hours per response, including the time for reviewing instructions, searching existing data 

sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required 

to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection 

of information, including suggestions for reducing this burden to CDC Reports Clearance Officer, 1600 Clifton Road, MS-74, Atlanta, GA 30333, ATTN: PRA (0920-0338). 
 

 

 

 

 

Form Approved 

OMB No. 

0920-0338 

Product category (check one) Exp.01/31/2026

______Dry snuff 

______Moist (wet) snuff 

______Snuff portion pouch 

______Snus 

______Snus portion pouch 

______Plug 

______Twist 

______Loose leaf 

______Compressed (pellet, tablet) 

______Other (specify) 

Documentation of method used for random sample section 

Documentation of Standards Addition Assay, including nicotine concentrations selected for standard curve 

Public reporting burden of this collection of information is estimated to average 1,706.5 hours per response, including the time for reviewing instructions, searching existing data 

sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required 

to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection 

of information, including suggestions for reducing this burden to CDC Reports Clearance Officer, 1600 Clifton Road, MS-74, Atlanta, GA 30333, ATTN: PRA (0920-0338). 
 

 

 

 

 

Form Approved OMB 

No. 0920-0338 

Exp.01/31/2026

Smokeless Tobacco Analytical Data 

Sample 

Date 

Manufacture 

Date 

Lot 

Number 

Sample 

Fraction1 

Age of the 

product in days 

when received 

by testing 

facility/storage 

conditions prior 

to analysis Nicotine2 

Total 

Moisture3 pH 

Estimated 

unionized 

(free) 

nicotine2 

Estimated 

unionized 

(free) 

nicotine3 

1 

2 

3 

4 

Final mean 

value with 95% 

confidence 

interval 

Range of values 

Estimated 

precision of the 

mean4 

1

Number of randomly sampled, sealed, packaged (so as to be representative of the product that is sold to the public) smokeless tobacco 

products selected per sampling date; 2

Units for nicotine and estimated unionized (free) nicotine content are milligrams of nicotine (or unionized 

(free) nicotine) per gram of tobacco (mg/g); 3

Total moisture and estimated unionized (free) nicotine as a percentage (%); 4Reported as the 

standard deviation. 

Public reporting burden of this collection of information is estimated to average 1,706.5 hours per response, including the time for reviewing instructions, searching existing data 

sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required 

to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection 

of information, including suggestions for reducing this burden to CDC Reports Clearance Officer, 1600 Clifton Road, MS-74, Atlanta, GA 30333, ATTN: PRA (0920-0338).